Calvert County Nursing Ctr.

F-F689. This was true for 1 out of the 29 residents reviewed during this survey.

The findings include:

1) Based on reviews of medical records, administrative records, and staff interviews, it was determined the facility staff failed to provide a resident with a safe environment, during a transfer from the bed to the wheelchair.

Review of Resident #417's fall prevention care plan initiated on 8/11/2024 revealed Resident #417 was at high risk for falls.

A review of Resident #417's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of 4/20/24 Quarterly, was conducted. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provides the appropriate care and services to the resident and to modify the care plan based on the resident's status.

MDS Section GG: Functional Abilities is coded to reflect that Resident #417 depends on staff for transfers (how the resident moved between surfaces including to or from the bed, chair and wheelchair and required

the support of two or more individuals to transfer.

Review of the facility reported incident MD00210322 on 8/23/24 at 9:59 AM, the date of the incident, revealed that the resident reported to the Director of Nursing that the Aide did not transfer her correctly. The resident explained that the GNA2 bear hugged her/him, and the arms were around the GNA2 neck when he/she lifted her.

On 1/15/25 at 9:30AM, an interview with the resident revealed that the resident was getting ready to attend

an activity and her Geriatric Nursing Assistant (GNA) was helping another resident. GNA 2 and GNA 3 came into the room to help her transfer from the side of the bed to the wheelchair. GNA 2 said they could lift the resident to the wheelchair, the resident and GNA 3 said that the resident was to be transferred via a sit to stand. A sit-to-stand device is meant to replace the manual stand-and-pivot transfer that's performed frequently by caregivers when transferring a weight-bearing resident/patient from a seated posture to a standing posture or different seated surface. The resident stated that's she felt the pain in her arm and heard

the snap when she lifted her arms around the GNA's neck.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215188 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 1/15/25 at 11AM, GNA 3 revealed the resident was a sit-to-stand transfer and offered to get the resident

the sit-to-stand device but, GNA 2 was in a hurry and lifted the resident. They said that they did hear the Level of Harm - Actual harm snap of the resident's arm. I immediately got the RN and then stayed with the resident to comfort them

Residents Affected - Few On 1/15/25 at 12 PM, an interview with the Director of Nursing revealed that resident had a sit-to-stand lift transfer initiated on 2/4/22 and it was continued to this day. GNA 2 did not follow the GNA transferring Kardex. The resident was sent to the emergency room for treatment of the right fractured arm. Education to staff on the protocol for safe lifting and movement of resident requiring a sit-to stand lift transferwas completed on 9/27/24.

On 1/15/25 at 2:30PM, an interview with the Director of Nursing stated the delay in education was that the resident failed to inform staff at the time of the incident that the sit-to-stand device was not used in the transfer.

On 1/16/25 at 8:55 AM, an interview with the Administrator revealed a Quality Assurance Performance Improvement (QAPI) action plan, completed 9/27/24, that identified what occurred i.e. full house education including agency staff and the suspension of GNA2. GNA2 was not allowed to return to the facility. There have been no new agency staff since this occurred. If new agency staff are to start work in the facility, they are educated on the transfer procedures for the residents. The plan of correction to address the facility's failure to be in compliance was completed by 9/27/24 and training is ongoing as needed for agency staff

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215188 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37296 potential for actual harm Based on record review and interviews, it was determined that the facility failed to develop and implement a Residents Affected - Few process to determine if residents with a history of trauma received the appropriate trauma informed care.

This was evident for 3 (#421, #406 and #407) of 3 residents reviewed for trauma informed care.

The findings include:

1) On 1/14/24 at 9:30 AM, a review of complaint MD00204534 dated 4/9/24 revealed that Resident #421 felt uncomfortable when she/he was bathed by the Geriatric Nursing Assistant.

Further medical record review for Resident #421 revealed the resident was admitted to the facility on [DATE REDACTED].

The review of the trauma informed care assessment completed on 12/31/23, 8/23/24, and 11/11/24, revealed that the resident did not experience any traumatic event such as accident, sexual assault or abuse.

On 1/25/24 at 1:13 PM, an interview with the Director of Social Work revealed on 4/10/24, the resident claimed that she was sexually abused in the past. When the Director of Social Work asked the resident why she/he didn't reveal the sexual trauma? The resident stated she forgot. The Surveyor reviewed the trauma informed care assessment with the Director of Social Work dated 8/23/24 and 11/11/24, and that it did not indicate that trauma occurred. The Director Social Work stated that I should have updated the trauma informed care assessment when the information was revealed to me.

42886

2) On 1/5/23, the State of Maryland's Office of Health Care Quality received a facility reported incident which reported that Resident #406 alleged that a male staff member touched the resident inappropriately.

Review of Resident #406's medical record on 1/16/25 at 11:25 AM revealed a written statement by hospice volunteer #12 which reported that Resident #406 told hospice volunteer #12 that a male GNA touched the resident inappropriately. An additional review of the resident's medical record on 1/16/23 at 11:50 AM revealed no evidence that a trauma informed assessment was performed to ensure the resident's care was appropriate.

On 1/16/25 at 1:30 PM, the survey team reviewed interviews with the Social Work Director and nursing staff regarding the facility's policies on trauma informed care. The review determined that trauma informed care assessments are completed when a resident is admitted and at a change of condition to ensure that the resident is receiving appropriate care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215188 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 On 1/17/25 at 10:00 AM, the surveyor interviewed the Director of Nursing (DON) and Administrator regarding

the trauma informed care policy. The DON and the Administrator confirmed resident trauma informed Level of Harm - Minimal harm or assessments should be done at admission and after a change in condition. The surveyor pointed out that potential for actual harm Resident #406 alleged that he/she was touched inappropriately and a review of the resident's medical record revealed no evidence of a trauma informed care assessment after the resident's allegation. The DON and Residents Affected - Few the Administrator reviewed the resident's medical record and confirmed that there was no evidence of a trauma informed care assessment.

3) On 5/10/23, the State of Maryland's Office of Health Care Quality received a facility reported incident which reported that Resident #407 alleged that a staff member slapped the resident in the face.

Review of Resident #407's medical record on 1/16/25 at 1:00 PM revealed a written statement by hospice volunteer #12 which reported that Resident #407 told his/her spouse that a staff member slapped the resident on the face on the evening of 5/9/23. An additional review of the resident's medical record on 1/16/23 at 1:10 PM revealed no evidence that a trauma informed assessment was performed to ensure the resident's care was appropriate.

On 1/16/25 at 1:30 PM, the survey team reviewed interviews with the Social Work Director and nursing staff regarding the facility's policy on trauma informed care. The review determined that trauma informed care assessments are completed when a resident is admitted and at a change of condition to ensure that the resident is receiving appropriate care.

On 1/17/25 at 10:00 AM, the surveyor interviewed the Director of Nursing (DON) and Administrator regarding

the trauma informed care policy. The DON and the Administrator confirmed resident trauma informed assessments should be done at admission and after a change in condition. The surveyor pointed out that Resident #407 alleged that he/she was slapped by a staff member and a review of the resident's medical

record revealed no evidence of a trauma informed care assessment after the resident's allegation. The DON and the Administrator reviewed the resident's medical record and confirmed that there was no evidence of a trauma informed care assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 215188